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TO:  All Providers

The Agency is providing the following clarification regarding reimbursement by RCOs for services provided to RCO Enrollees by out-of-network providers. This guidance only applies to the populations and the services included in the RCOs. For a listing of the populations and services included in the RCO please visit the Medicaid website at:

http://www.medicaid.alabama.gov/content/5.0_Managed_Care/5.1_RCOs/5.1.1_RCO_Basics.aspx

Pursuant to 42 C.F.R. §§ 438.114(c)(1)(i) and 438.206(b)(4)-(5), an RCO is required to reimburse an out-of-network provider (i.e. a provider who has not entered into a provider contract with an RCO) for services performed on behalf of a Medicaid beneficiary enrolled in an RCO (Enrollee) under the following two circumstances:

(1)  An RCO must pay an out-of-network provider for emergency services provided to an Enrollee in that RCO. (Under the risk contract, the out-of-network provider may be reimbursed no more than the amount that would have been paid if the emergency services had been provided under the Medicaid Fee-for-Service program.)

(2)  An out-of-network provider may be reimbursed for services performed through a single-case agreement with an RCO for a specific service for a specific Enrollee, if the RCO cannot provide the specific covered service through its provider network. The out-of-network provider must coordinate with the RCO with respect to the reimbursement amount, but the RCO must ensure that the cost to the Medicaid beneficiary is no greater than it would be if the services were furnished within the RCO’s provider network.

Under either of these circumstances, the out-of-network provider is not guaranteed any particular rate of reimbursement for services provided to the RCO Enrollee.

The Agency encourages RCOs and providers to enter into provider contracts so that service delivery networks may continue to expand and providers may have more certainty regarding reimbursement for services. As RCOs and Medicaid providers continue to negotiate contracts for the provision of care under the RCO program, the Agency reminds these parties of the provider contract dispute procedures available through Section 22-6-153 of the Alabama Code and Rule 560-X-62-.11.

Information about RCOs, implementation or other aspects of this managed care program may be found on the Agency’s RCO webpage at: http://www.medicaid.alabama.gov/content/5.0_Managed_Care/5.1_RCOs.aspx.

Provider questions may be emailed to RCOportal@medicaid.alabama.gov

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